Module 2
Risk Adjustment in MA
Risk scores multiply payment for 35 million people. How the model works here, what coding intensity costs, and how audits and courts are reshaping enforcement.
By the end of this module, you will be able to:
- Explain why risk scores carry more financial weight in MA than in other programs
- Interpret current coding intensity estimates and the effect of the v28 model
- Describe how RADV audits work and the current status of extrapolation
- Risk Scores in Medicare Advantage Risk adjustment matters more in MA than anywhere else, because it sets the payment for 35 million people. This lesson covers how it works here. About 4 min
- Coding Intensity MA risk scores run higher than traditional Medicare for comparable people. This lesson reports what the current estimates actually say. About 5 min
- Audits and Integrity RADV audits check whether coded diagnoses are supported by the record. This lesson covers how they work and the litigation that has reshaped them. About 5 min
Module quiz
Answer all questions to see your score.
1. Why does risk adjustment carry more financial weight in Medicare Advantage than elsewhere?
A few percentage points of average risk score across roughly 35 million people is worth billions, which is why MA coding is so scrutinized.
2. What does coding intensity mean?
It is a gap in recorded diagnoses rather than in actual illness, and MedPAC still estimates MA coding runs about 10.3 percent higher than fee-for-service.
3. What is the current status of extrapolation in RADV audits?
CMS expanded audits to roughly 550 contracts a year, but a 2025 decision vacated the extrapolation rule, so verify the current posture before relying on it.